Nokea
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
You may also like to solve these questions
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
- A. Breath sounds can be heard bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88 BPM
- D. Client is unable to speak
Correct Answer: C
Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
The nurse provides a collection container to the client for collecting a sputum specimen for culture and sensitivity. Which additional interventions should the nurse implement? Select all that apply.
- A. Tell the client to spit into the container 2 to 3 times during the day.
- B. Wear gloves and protective eyewear when handling the specimen.
- C. After collection, place the sealed container in a clean plastic bag.
- D. Place a biohazard alert symbol on the bag containing the specimen container.
- E. Send the specimen to the laboratory within 30 minutes of collection.
Correct Answer: C,D,E
Rationale: C: A clean bag prevents external contamination. D: A biohazard symbol indicates infectious material. E: Prompt delivery ensures accurate results. A: Single morning collection is preferred. B: Eyewear is unnecessary.
The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
- A. lower extremity pitting edema
- B. rales
- C. jugular vein distension
- D. weakness in left arm
Correct Answer: D
Rationale: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies.